Stroke Flashcards
aims of stroke management
- is the disability reversible with treatment? ie timeframe
- rehabilitation - how to help patient back to living their life
- how to prevent next stroke?
thrombolysis
<4.5hr
thrombolysis timeframe
what is used?
<4.5hr
recombinant tPA / alteplase
ischaemic stroke management
thrombolysis
thrombectomy
neuro plasticity
brain tissue surrounding damaged brain re learns how to perform certain action
stroke is a clinical diagnosis, true or false
true
3 hallmarks of stroke
- acute onset - when did it start?
- focal neurological deficit
- disrupted blood flow / vascular cause: ischaemia vs haemorrhage
D.Dx of stroke ie stroke mimics
Bells palsy Migraine Todd's paresis (post-ictal) Hypoglycaemia acute on chronic: brain tumour, MS, bleeding Functional - non consistent symptoms
how to differentiate between types of stroke
non-contrast CT head
which is more common, ischaemic or haemorrhagic stroke
ischaemic
risk of having a second event is extremely high immediately after the first event, true or false
true
intracranial haemorrhages are not all stroke, true or false
true
can get extra/subdural/subarachnoid haemorrhages which is not the same as a stroke
describe the bleeding in a haemorrhagic stroke
intracerebral haemorrhage causing compression
neurosurgery will reverse haemorrhagic stroke, true or false
false
not usually involved unless life threatening
it will still not reverse the disability
haemorrhagic stroke is the same as intracerebral haemorrhage
yes
causes of haemorrhagic stroke
anticoagulants perpetuate blood loss hypertension arteriosclerosis amyloid angiopathy vasculitis - any layer of vessel wall AVM aneurysms (more likely to be SAH) extravascular causes: - bleeding into tumour - abscess
arteriosclerosis vs atherosclerosis
arteriosclerosis - not intimal disease, disease of tunica media muscle layer, calcification leads to hardening of artery like a tendon, can snap and bleed
not necessarily a HTN disease, more ageing
atherosclerosis - intimal disease with plaque deposition and cholesterol
types of intracerebral haemorrhages
peripheral /lobar haemorrhage
deep haemorrhage - more likely to be secondary to HTN
which carotid artery is concerned with the brain
ICA
where do the vertebral arteries arise from
subclavian arteries
where is the circle of willis found
CSF / subarachnoid
importance of circle of willis
collateral circulation to brain
large vessel occlusion almost always ischaemic
embolic
do it again
looks for source of embolus
ECG, scan…
what is affected in lacunar stroke
small infarcts from perforating arteries
thrombus
TIA
autothrombolyse
large vessel occlusion
cortical involvement
small vessel infsarcts
deep
how to differentiate between large and small vessel infarct
cortical involvement
large - cortical involvement
cortical signs
functions served by cerebral cortex
dominance
right vs left
deals with communication
examples of cortical dysfunction
dysphasia
dysarthria
slurring of speech
not a neurological in origin, it is physical
dysphasia
due to brain damage
difficulty in communication
loses ability to understand
receptive dysphasia
‘fluent’
can talk back to you fluently but not the correct content
loses ability to express themselves
expressive dysphasia
can understand you and follow instructions
but grammatically incorrect
non fluent
agnosia
failure to recognise an object despite having intact motor, sensory and visual sensation
apraxia
knowing it is a pen but unable to use it
right hemisphere sided cortical infarct
neglect - left side doesnt exist, only right side, sitting up straight feels like pushing
changes in personality
sensory inattention
inattention - failure to pick up
subtle signs of RHS
3D
spatial disorientation
changes in personality
TACS
embolic
lacs
physically disabled but able to communicate
PACS
EMBOLIC
LACS
intact cortex
POCS
vertebrobasilar system
TOAST classification for ischaemic strokes and TIA
- cardioembolic - AF
- large vessel atheroembolic - atherosclerosis
- small vessel - thrombotic disease
- infarcts due to other determined causes: dissection, hypoperfusion, vasospasm, paradoxical embolism, venous infarct
- cryptogenic - unknown cause
Watershed stroke
border
what is a venous infarct
gradual onset, diffuse symptoms with inclear origins
essentially a DVT in the veins of the brain
more likely to be haemorrhagic
need anticoagulation
venous sinus clogging
paradoxical embolism as a cause of stroke is treated with thrombolysis, true or false
true
TIA is a stroke mimic?
NO
TIA is a stroke
difference between TIA and stroke
TIA - no disability
stroke - disability
what is a TIA
transient neurological symptoms without brain damage
TIAs need urgent investigation and management?
yes!
commonest cause of AF
HTN
Investigations for stroke
bloods - FBC, U+E, LFT, lipids, glucose, clotting ECG carotid doppler ambulatory monitoring ECHO
> ? stenosis of carotid arteries qualify for carotid endarterectomy
> 70%
when would you do a carotid endarterectomy for a patient with stroke/TIA
within 2 weeks of event
otherwise no benefit
drugs for secondary prevention of stroke
antiplatelets anticoagulants statins anti hypertensives DM lifestyle MDT
What type of strokes would you use antiplatelets as secondary prevention for
ischaemic stroke
- large vessel atheroembolic
- small vessel
types of antiplatelets used for stroke prevention
aspirin
clopidogrel
dipyridamole
antiplatelet therapy post stroke
2 weeks of 300mg aspirin
then 75mg clopidogrel lifelong
3 causes of stroke you would give anticoagulants to
cardioembolic
paradoxical embolic infarct
venous infarcts
types of anticoagulants
warfarin
DOACs - dabigatran, apixiban, rivaroxiban, edoxiban
INR of __ can still be thrombolysed
INR <1.5 can receive thrombolysis
a patient on a DOAC automatically are excluded from thrombolysis, true or false
true
what test can monitor warfarin
INR
which one gives you predictable anticoagulation, warfarin or DOACs
DOACs
warfarin/DOACs have variable dosing
warfarin has variable dosing
warfarin/DOACs have fewer drug interactions
DOACs have fewer interactions
prothrombin complex is used to reverse which anticoagulation?
warfarin
delay start of anticoagulation depending on size of infarct, true or false
true
if there is no/small infarct, you can start it straight away
if it is larger, then there is a greater risk of haemorrhagic conversion
which antihypertensives are thought to be effective in HTN for stroke
ACEI/ARBs
thiazide diuretics
CT is better/worse at picking up acute stroke whereas MRI is better/worse at picking up acute stroke
CT better for acute stroke
MRI better for old stroke haemorrhage
when the brain tissue is ischaemic, you lose the grey white interface, true or false
true
when you have large infarcts, it may be normal to have haemorrhagic transformation
yes
what is the main thing to rule out on imaging for stroke
haemorrhage
dense vessel
thrombus in blood vessel
deep infarct with sparing of the cortex
lacunar stroke
